Browsing by Author "Green, Eric P"

Background: An estimated 2.6 million children under 15 years are living with HIV. Children often begin antiretroviral therapy (ART) without learning why they are sick or the purpose of their medication. The objective of this study was to estimate the prevalence of pediatric HIV disclosure in two districts in rural Zimbabwe, characterize the process of disclosure, and begin investigating the predictors and consequences of disclosure.

Methods: This was a cross-sectional survey of 372 primary caregivers of HIV-positive children between the ages of 9 and 15 years living in Bikita and Zaka districts and receiving ART or pre-ART from a network of 21 eligible clinics. Surveys were administered individually in Shona by trained Zimbabwean enumerators. Disclosure was referred to if a child knows he or she has a health condition called HIV. Full disclosure was defined as a caregiver's report that the child knows he or she has an illness called HIV, how he or she acquired the illness, and can pass the infection to someone else. The prevalence of disclosure was estimated for the overall sample, by district, and by clinic. Characteristics of the process of disclosure as well as predictors and consequences of disclosure were identified for the overall sample.

Results: The overall prevalence of disclosure in the sample is 66.9 percent (95% CI 62.0 to 71.5%). Disclosure rates are similar across districts: 64.1 percent in Bikita (56.5 to 71.7%) and 69.0 percent in Zaka (62.8 to 75.2%). Across the 21 study clinics, disclosure rates ranged from 47.8 to 85.7 percent. Among the children who know that they are HIV-positive, 69.9 percent know how they were infected (63.9 to 75.2%) and 48.6 percent know that they could pass the infection to someone else (42.5 to 54.8%). The average child learned about his or her illness at age 10.0 (SD=1.9). In the majority of cases, the caregiver informed the child directly (58.6%) and 28.5 percent of children learned of their status from a health worker. Most caregivers who have disclosed to their child reported that their overall disclosure experience was positive (81.5%), with 76.7 percent having improved their adherence to medication following disclosure. Predictors of disclosure were identified as follows: caregivers’ high level of self-efficacy to disclose (p<0.05); HIV-positive caregivers’ high level of HIV-related shame (p<0.001); HIV-positive caregivers’ high level of awareness of their own HIV symptoms and implications of HIV on their health and future (p<0.05); caregivers’ assessment that their child has cognitive skills and is emotionally mature (p<0.10); higher levels of child’s formal education (p<0.05); and caregivers who are not currently married or living with someone else (p<0.01). The following were not predictors of disclosure: caregivers’ assessment of benefits of disclosure outweighing the risks of disclosure, perception of HIV-related stigma and/or discrimination, access to health care, quality of health care, child or caregiver gender, or socioeconomic status did not appear to influence the caregivers’ decision to disclose to their child.

Conclusions: Caregivers who are taking care of children between the ages of 9 and 15 need proper support and assistance from health workers for pediatric HIV disclosure. More efforts are needed to encourage and assist caregivers to inform their child about his or her HIV status. In the future, helpful disclosure support interventions would address caregivers’ HIV-related shame, improve the psychosocial wellbeing of the caregivers, educate caregivers about HIV and HIV treatment, and help them improve parent-child communication, all of which may allow caregivers to increase their overall self-efficacy and therefore facilitate a successful, age-appropriate disclosure process for both the caregivers and their children.

Background: An estimated 225 million women globally have an unmet family planning need, three-quarters of whom live in low and middle-income countries. Addressing this need requires new and innovative approaches, such as digital health solutions. We examined the impact of a new phone-based screening and referral service on the take-up of family planning as part of a pilot study to prepare for a full trial of the intervention.

Methods: This pilot study tested the procedures for a randomized encouragement trial. We recruited 112 women with an unmet need for family planning from local markets in Western Kenya, conducted an eligibility screening, and randomized half of the women to receive an encouragement to try the investigational intervention. Four months after sending an encouraging to the treatment group, we attempted to conduct a follow-up survey with all enrolled participants.

Results: The encouragement sent via text message to the treatment group led to differential rates of intervention uptake between the treatment and control groups, but take-up among the group was lower than anticipated (33.9% vs 1.8% in the control group). Study attrition was also substantial. We obtained follow-up data from 44.6% of enrolled participants. Among those in the treatment group who tried the intervention, however, the instrumental variables estimate of the Local Average Treatment Effect was an increase of 41 percentage points in the probability of contraceptive take-up.

Conclusion: This randomized encouragement design and study protocol is feasible but requires modifications to the encouragement and follow-up data collection procedures. The investigational intervention appears to have a positive impact on contraceptive take-up among women with an unmet need despite a number of contextual challenges.

Every day, approximately 800 women die from pregnancy-related complications. Most of these deaths are avoidable. Care from a skilled provider before, during, and after delivery has been shown to prevent a majority of maternal and neonatal deaths. However, time delays in recognizing the need to seek care, accessing health care facilities, and receiving adequate care from a provider of make the delivery of effective maternal healthcare practices very challenging. These three delays disproportionately affect women living in rural and remote regions, where awareness of maternal health problems can be low and health facilities are few and far between. In Kenya, maternal health care in these regions falls upon community health volunteers, who are unpaid and overworked.

In recent years, mobile phones have grown in popularity for improving disease prevention and management, especially in the field of maternal and child health. The intent of this study was to design and pilot a mobile phone-based patient management system intended for use by community health volunteers. Using a human-centered design framework, a system was developed to fit into the CHVs' existing workflows in order to improve the delivery of maternal and child health care at the community level. Integrating both voice and text messaging interfaces, the system was designed to provide the CHVs with a fast and easy method of recording and reporting data, a streamlined approach for tracking patient referrals to a health facility, and a reliable and effective way to report and respond to obstetric emergencies. The system was found to be highly usable based on self-report data from users, who indicated that the system saved them time and helped them complete their responsibilities as CHVs. In all, results of this pilot suggest that such a system may be useful for CHVs in monitoring the health of pregnant women over time and helping to avoid the time delays associated with maternal mortality.

Background: Depression-screening tools exist and are widely used in Western settings. There have been few studies done to explore whether or not existing tools are valid and effective to use in sub-Saharan Africa. Our study aimed to develop and validate a perinatal depression-screening tool in rural Kenya.

Methods: We utilized conducted free listing and card sorting exercises with a purposive sample of 12 women and 38 CHVs living in a rural community to explore the manifestations of perinatal depression in that setting. We used the information obtained to produce a locally relevant depression-screening tool that comprised of existing Western psychiatric concepts and locally derived items. Subsequently, we administered the novel depression-screening tool and two existing screening tools (the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire-9) to 193 women and compared the results of the screening tool with that of a gold standard structured clinical interview to determine validity.

Results: The free listing and card sorting exercise produced a set of 60 screening items. Of the items in this set, we identified the 10 items that most accurately classified cases and non-cases. This 10-item scale had a sensitivity of 100.0 and specificity of 81.2. This compared to 90.0, 31.5 and 90.0, 49.7 for the EPDS and the PHQ-9, respectively. Overall, we found a prevalence of depression of 5.2 percent.

Conclusions: The new scale does very well in terms of diagnostic validity, having the highest scores in this domain compared to the EPDS, EPDS-R and PHQ-9. The adapted scale does very well with regards to convergent validity-illustrating clear distinction between mean scores across the different categories. It does well with regards to discriminant validity, internal consistency reliability, and test-retest reliability- not securing top scores in those domains but still yielding satisfactory results.

Background: Perinatal depression in low- and middle-income countries (LMICs) is common and associated with many negative outcomes. Although effective interventions exist, many cases in LMICs remain untreated due to a lack of human resources. Task-sharing approaches such as Thinking Healthy program were proved to be feasible to expand access to treatment in LMICs but were facing certain barriers to scale up. In this study, we adapted Thinking Healthy Program to the artificial intelligence system called Tess (named Zuri in Kenya) to provide automated psychological support for perinatal women in Kenya. The objective was to gather preliminary data on feasibility, acceptability, and perceived impacts of the automated psychological support on perinatal women in Kenya.

Methods: Women were recruited from two public hospitals in Kiambu County, Kenya. After enrollment, each woman was matched to another new participant with similar maternity status and was randomly assigned to have a 1-week or 2-week baseline period. We prompted participants to rate their mood every 3 days throughout the study. We also reviewed system logs and conducted in-depth interviews to determine feasibility, acceptability, and perceived impacts of the intervention.

Results: 647 women were invited to participate; 86 of them completed the SMS screening and 41 of them enrolled in the study. Among all the enrolled participants, 27 of them (65.9%) sent at least one message to Zuri and 31 (75.6%) of them submitted at least three ratings. 14 women (34.1%) engaged with Zuri beyond registration. Free chats were a big part of the participants’ interactions with Zuri. During free chats, the most common intervention module was mindfulness-based meditation, and the most common rapport-building module was discussion about the women’s passion. Most interviewees expressed positive attitudes towards Zuri. They also reported some positive changes in their life after using Zuri.

Conclusion: The preliminary data showed that Zuri was feasible, acceptable, and had some perceived impacts among a sample of pregnant women and new mothers in Kenya. Automated psychological support is still in its infancy, but it has great potential to close the large treatment gap that exists in many LMICs.

Despite the clear benefits to women, families, and society, family planning is not universal. In 2015,12 percent of married or in-union women who want to prevent or delay pregnancy were are not currently using a method of family planning in 2015. In Africa, this rate is even higher, at 24 percent. In order to meet the unmet need for family planning, new approaches to service delivery are required. A critical question for anyone interested in ensuring universal access to sexual and reproductive health-care services like family planning is how to create new products, services and implementation models that work for users. The objective of this case study is to describe how Human Centered Design (HCD) was used to develop a digital marketplace for family planning in Kenya, called Nivi, and draw lessons for broader application to global health challenges. By using the HCD approach, we sought to better understand the challenges users face with the Nivi platform and the opportunities that exist to make improvements. By incorporating HCD, we were able to build a service with greater potential for use and usability for Nivi users. We believe that taking an HCD approach allowed us to build a product that has the potential to meet the unmet need for family planning services in Kenya. This case study highlights the strengths and challenges to inform the use of HCD for other health applications in emerging markets.

Background: The U.S. maternal mortality ratio (MMR) is 23.8 deaths per 100,000 live births. This ratio is the highest among high-income countries. Women of color (Black, Alaska Native, and American Indian women) disproportionally contribute to this statistic; they are 2 to 3 times more likely to die from pregnancy-related complications compared to white women and are more likely to be on Medicaid. This study focuses on FemTech’s (broadly defined as diagnostics, software, products, and services for women) role in maternal healthcare. The purpose of this research is to better understand how companies serve women of color and Medicaid recipients and the barriers that prevent them from doing more. Methods: Fifteen semi-structured interviews were conducted. Stakeholder categories included Medicaid representatives, FemTech startups, healthcare providers, healthcare consultants, and venture capitalists. All interviews consisted of approximately 6-8 open-ended questions and were analyzed through an emergent coding process focused on identifying interviewee themes. Results: This study found that startups mainly provided family planning offerings to women of color and/or Medicaid recipients during the prenatal and postpartum period. Key gaps that FemTech companies did not address include inaccessible pricing and lack of chronic condition management through primary care. These gaps are in line with broader FemTech trends. Conclusions: Until FemTech products and services address these gaps, they are unlikely to reduce maternal health disparities significantly.